Blurring the Lines

Like it or not, the American public doesn't really know what an optometrist is. Last weekend I was watching The Practice on ABC, one of the few television shows that I watch regularly. This is an intelligent drama series, created by highly respected writer/producer David E. Kelley, that regularly addresses difficult societal issues in a cerebral manner. In this episode a prisoner was discussing his visual symptoms with one of the show's attorneys. He had been examined by the prison optometrist and, in discussing the care he had received, implied that the doctor had attended medical school. Unfortunately, David Kelley is probably not part of a naïve minority. A recent survey conducted by the American Academy of Ophthalmology and the Wisconsin Academy of Ophthalmology found that 52% of those polled incorrectly stated that optometrists are graduates from an accredited medical school, and that 15% think optometrists are licensed to perform surgery. These are honest errors, no different from mispronouncing the word “astigmatism,” or mistakenly voting for the wrong presidential candidate. The public's confusion does raise a number of important questions. Does optometry benefit or suffer from this common misconception? Has optometry added to the confusion among the public? As a profession we have aggressively and successfully sought increases in our scope of practice. The ability to treat disease with topical and oral drugs has enlarged the overlap with the practice of ophthalmology and contributed to the public's confusion. Likewise, the adoption of the term “optometric physician” by state optometric associations in, for example, Washington and New Jersey has blurred the lines further. Legislators may be no wiser than their constituents. A state association executive director informs me that he regularly has to educate representatives to the difference between the three O's—optometrist, optician, and ophthalmologist. Even a member of the Senate Education Committee, who had sponsored an opticians’ bill to expand their scope of practice, confused opticians with optometrists. Looking around, there appears to be one group that can reliably tell the difference. Health maintenance organizations can and do discriminate between ophthalmology and optometry by restricting the providers from whom a patient can receive eyecare. Legislation like the Ohio Optometric Association's Patient Access Bill seeks to eliminate or minimize this discrimination. This bill would allow patients more choice in choosing an eyecare practitioner. Specifically, it would enable patients whose health insurance changes to stay under the care of their optometrist and thus enjoy the benefits of continuity of care. Given optometry's past successes, it is reasonable to anticipate that other eyecare professionals will be equally aggressive in the legislative arena. A number of states have seen the introduction of legislation that would allow opticians to refract and prescribe spectacles. Furthermore, there is legislation pending in the New Jersey Legislature that threatens to prohibit optometrists from supplying glasses or contact lenses to their own patients. Proponents of the legislation argue that this practice—arguable the practice of optometry—represents self-referral and should be prohibited in the same way that similar practices by physicians are forbidden under the federal Stark Law. The bill pending in New Jersey may represent the first serious attempt to fundamentally contract our scope of practice, In summary, the expansion of optometry's scope of practice may have inadvertently blurred our patients’ distinction between optometrist and ophthalmologist. As a profession, we should decide whether we are comfortable with this confusion and, if not, what steps should be taken to clarify our role in the eyes of the public. In the meantime, I am off to find my old copy of Orwell's Animal Farm.